Page 1 of 5 TITLE: COMMUNITY-ACQUIRED PNEUMONIA (CAP) EMPIRIC MANAGEMENT OF ADULT PATIENTS AND IV TO PO CONVERSION GUIDELINES: These guidelines serve to aid clinicians in the diagnostic work-up, assessment of severity of illness, empiric antibiotic treatment, and follow-up of adult patients with community-acquired pneumonia (CAP). These guidelines have been developed based on published literature including the most recent CAP guidelines and expert clinical opinions. 1-2 The recommendations serve as a guide and clinicians are encouraged to use clinical judgment to manage all cases. PURPOSE: To develop guidelines for the use of appropriate antibiotics for adult patients with CAP and guidance on IV to PO conversion. APPLICABILITY: Prescribers and pharmacists PROCEDURE: 1. Initial approach (See algorithm) A. Diagnostic studies B. Patient stratification 1) Pneumonia PORT Severity Index 2) Patients with asthma have increased risk of complications and may warrant hospital admission. C. Need for hospitalization 1) In general, patients in risk Class I and II may be managed as outpatients. Outpatient management of patients in risk Class III may be considered after assessment of patient s clinical condition, follow-up, and home environment. D. Need for admission to an intensive care unit 2. Empiric antibiotic therapy (See algorithm) A. Outpatient therapy B. Inpatient antibiotic therapy 1) Risk factors
Page 2 of 5 a. Initial therapy should be individualized where appropriate based on antibiotic history, recent hospitalization, immune status, and culture history. 2) Non-ICU admission 3) ICU-admission C. Every effort should be made to initiate antibiotic therapy as soon as possible D. Antibiotic therapy should always be targeted to culture and susceptibility data when available** 3. IV to PO Conversion (See algorithm) A. Recommendations for oral conversion are provided based on initial IV therapy. The choice of oral antibiotics may be influenced by results of microbiologic studies, favoring more-narrow spectrum agents when possible. B. Recommendations have been made to convert intravenous ceftriaxone, a third generation cephalosporin, to oral cefuroxime, a second-generation cephalosporin. Intravenous ceftriaxone has no definitive oral equivalent and conversion to cefuroxime (Ceftin) should be adequate following initial therapy with ceftriaxone. If a specific pathogen is identified, therapy should be modified accordingly. 4. Discharge (See algorithm) 5. Algorithm A. Prior to discharge, all patients should be screened for influenza vaccination during influenza season, pneumococcal vaccination, and the need for smoking cessation counseling. 3-5 (A list of steps taken to carry out the policy. A How To guideline for executing the policy.)
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Page 5 of 5 RESPONSIBILITY: Joint Subcommittee on Anti-Infective Use REFERENCES: 1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 suppl 2: S27-72. 2. Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001 Jun; 163(7): 1730-54. 3. Centers for Disease Control. Influenza (Flu). http://www.cdc.gov/flu/ 4. Centers for Disease Control. Adult immunization schedule. http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm 5. Centers for Disease Control. Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR April 04, 1997; 46(RR-08); 1-24. POLICY/GUIDELINE DATES: Issued: October 2004 Reviewed: May 2010 Revised: April 2010 Medical Board Approval: June 2010